1. Field of the Invention
This invention relates to electronic payment systems. More specifically, it relates to a method of using check image viewing infrastructure that already exists in bank online portals to display sensitive protected health information such as explanation of benefits to healthcare providers for payment reconciliation.
2. Brief Description of the Related Art
Adjudication, payment and reconciliation of service provider claims against insurance carriers (particularly in the healthcare industry) consumes substantial time and resources. Third party administrators (herein “TPAs”), insurance companies, and large self-funded corporations (herein “Payers”) adjudicate claims, compare them to a benefit plan and make the decision to write checks in payment for the claims. Currently, many payers are required to print checks and explanation of benefit (EOB) forms for delivery to the healthcare providers. The EOB lists the amount the healthcare provider billed the Payer's company and the amount the Payer's company paid on the claim. It may also list the contractual discount amount and the patient responsibility. If the claim is denied, the EOB will explain the reason for denial.
In an effort to streamline this process, Applicant developed a process described in U.S. Pat. No. 7,792,686, the specification of which is incorporated herein by reference. The '686 patent discloses a method to deploy a single-load stored value card to pay medical service claims. Since there is a one-to-one relationship between the stored value card and the specific claim, reconciling the payment is made substantially more efficient. However, credit cards (whether stored-value cards, debit cards or the like) incur interchange fees. Thus, a service provider accepting a credit card payment might receive between 95-98% of the authorized payment funds after the transactional costs are deducted.
Electronic fund transfers (EFTs) do not incur the same transactional costs as do payment cards. An EFT is the electronic exchange or transfer of money from one account to another, either within a single financial institution or across multiple institutions, through computer-based systems. However, to set up an EFT the payee (the healthcare provider) would need to make available highly sensitive financial information such as the bank routing number and account number to the hundreds of third party administrators that adjudicate insurance claims.
Another issue with EFT payments is that under new electronic data interchange (EDI) standards, both payment and EOB information may be encoded into the EFT. Based on the Accredited Standards Committee (ASC) X12 format, the 835 transaction set can be used to make a payment and send an EOB. It can send an EOB only from a health-care insurer to a health-care provider, either directly or through a financial institution.
Unless a TPA produces an 835 that healthcare providers will accept, the TPA must still print an EOB, so the provider can reconcile it to their EFT payments. Since EFTs use trace numbers and printed provider EOBs (generally using check numbers marked “void”) it creates difficulties for providers to reconcile the EFT deposit to the paper EOB. This in turn can cause an increase in either the number of customer service calls or the provider resubmitting claims. If a TPA is successful in getting half of its healthcare providers to accept 835s this is still a low percentage of EOBs produced for providers. Only the larger healthcare organizations have the ability to accept both an EFT and 835, making them the TPA's largest payees. The means the TPA must still bear the additional expense of producing provider payments the vast majority of the time. Furthermore, receiving banks are hesitant to receive EOB information as it contains protected health information (PHI) which is subject to additional regulations regarding its privacy.
Yet another problem with EFT payments is that the healthcare provider might receive the payment funds from the TPA's EFT authorization, but would need separate logins to hundreds of TPA portals to retrieve EOB information. This would make reconciling nearly unworkable.
Nevertheless, there exists substantial motivation to move to EFT payments. According to the U.S. Healthcare Efficiency Index Fact Sheet, such a move would save $11 billion per year for the healthcare industry. Recent legislation in the United States includes modification of Section 1862(a) of the Social Security Act which mandates the use of EFT for all Medicare reimbursement to healthcare providers by Jan. 1, 2014. Congress has required the EFT and Electronic Remittance Advice (ERA) operating rules must be adopted by Jul. 1, 2012 and implemented no later than Jan. 1, 2014.
What is needed in the art is a method to provide healthcare providers a single login to reconcile both payments and EOBs.
Another need in the art is a method to bifurcate the payment data in an EFT (which banks are accustom to) from the PHI data which has privacy regulations banks find undesirable to accommodate.
Yet another need in the art is to utilize existing infrastructure in a novel way to deliver EOB data securely and linked with payment information for reconciling received funds.
However, in view of the art considered as a whole at the time the present invention was made, it was not obvious to those of ordinary skill in the field of this invention how the shortcomings of the prior art could be overcome.